57Good morning

splinting

Presenter:

Shashwati Paul

Post Graduate Student

Dept. of Periodontology

CONTENTS Introduction Definitions Terminology History When to splint.. Objectives of splinting Indications Contraindications Principles of splinting Ideal splint Mode of action

Classification of splints Temporary stabilization

Extracoronal splints

Internal splints Provisional splinting Permanent splinting Literature review Drawbacks of splinting Conclusion References

INTRODUCTION

The ultimate goal in successful management of mobile teeth is to restore function

and comfort by establishing a stable occlusion that promotes tooth retention and

the maintenance of periodontal health.

The clinical management of mobile teeth can be a perplexing problem..

In some cases, mobile teeth are retained because patients decline multidisciplinary

treatment that might otherwise also include strategic extractions.

Some mobile teeth can be treated through occlusal equilibration alone (primary

occlusal trauma) where as mobile teeth with a compromised periodontium can be

stabilized with the aid of provisional and/or definitive splinting (secondary

occlusal trauma).

Tooth splinting have been accomplished since ancient civilizations to decrease

tooth mobility and to improve form, function, and esthetics.

Still splinting remains one of the poorly understood & controversial areas of

dental therapy.

Definitions

An appliance for immobilization or stabilization of injured or diseased parts.

(Glickman 1972)

A splint is any appliance that joins two or more teeth to provide support.(Grant

1988)

According to Glossary of Periodontic Terms 1986 a splint is “an appliance designed

to stabilize mobile teeth”.

According to AAP (1996), a splint has been defined “as an apparatus,

appliance, or device employed to prevent motion or displacement of fractured

or removable parts.”

The Glossary of Prosthodontic Terms defines splint as “a rigid or flexible

device that maintains in position a displaced or movable part; also used to

keep in place & protect the injured part.”

Dawson defines splinting as “the joining of two or more teeth for the purpose

of stabilization”.

TERMINOLOGYSTABILIZATION: Stabilization of a tooth is an increase in resistance to applied force by providing

reciprocal antagonisms and increasing the effective root area. The force may remain the same, but the resistance is increased.

TEMPORARY SPLINT: This is used on a short term basis, usually less than 6 months, and is often advocated to

stabilize teeth during periodontal treatment. It may or may not 1ead to other types of splinting.

PROVISIONAL SPLINT: This type of splint is used for a longer period of time from several months to as long as

several years.

It allows the clinician to see how teeth will respond to treatment.

It usually leads to more permanent forms of stabilization.

PERMANENT SPLINTS:

Permanent splinting of teeth that have been treated periodontally is also referred to as

Periodontal prosthesis.

Periodontal prosthesis may be defined as those restorative and prosthetic endeavors

that are indicated and essential in the total treatment of advanced periodontal disease.

HISTORY A Phoenician mandible from 500BC and another Phoenician prosthetic

appliance was found from 400 BC in modern day that was comprised of two

carved ivory teeth attached to four natural teeth by gold wire.

Archeological excavations of the Etruscan society (Eighth century BC to the

first century AD) have found evidence of their use of wire ligation and gold

bands to stabilize teeth.

In early 1700s Fauchard attempted tooth ligation.

In the 1900s several authors described splinting techniques.

Hirschfeld(1950) was one of the first modern periodontal authors to advocate

ligation of periodontally diseased teeth using either stainless steel wire or silk.

His technique was extracoronal and involved only the anterior teeth.

In the last 50 years…..

WHEN TO SPLINT?

The splinting of mobile teeth is often, of value as a means of stabilization

before, during, and after periodontal therapy.

For most patients, splinting should be considered only after the preliminary

phase of periodontal therapy has been completed.

Cohen and Chacker have noted, "When large areas of attachment apparatus

have been destroyed, the artificial support offered by temporary stabilization

may allow a new, healthy tooth-bone relationship to be established.

Therefore it would seem advisable that when the treatment plan is being

formulated the need for stabilization be determined on the basis of the nature

and extent of the destructive process present.

Root planing, curettage, oral hygiene, and surgery may reduce the mobility as

inflammation is resolved.

Occlusal adjustment, restorative dentistry may alter occlusal relationships and

redirect forces, thereby reducing traumatism result in the teeth becoming firmer.

Increasing the support of loose teeth may also increase their firmness, the device

used for such treatment is the splint.

Two clinical features should be analyzed to understand the full scope of the

relationship between occlusal trauma and tooth mobility.

The first is increased tooth mobility.

This process is the adaptation of the periodontium to occlusal forces.

In the absence of inflammation, mobile teeth with a complete and healthy

connective tissue attachment can be maintained.

The radiographic appearance of a widened periodontal ligament (PDL) space

coupled with a clinical diagnosis of increased tooth mobility may merely be

manifestations of adaptive changes to increased functional demand.

Removal of the excess occlusal load through equilibration and perhaps,

conventional splint therapy can decrease and, often at times, eliminate tooth

mobility.

An occlusal equilibration that equalizes the occlusal stresses, produces

simultaneous tooth contacts, or harmonizes cuspal relations may be all that is

needed to reverse this mobility.

The second clinical feature is increasing tooth mobility.

This clinical condition is best managed by treating any localized inflammation,

performing an occlusal equilibration, and perhaps stabilizing or splinting the affected

mobile teeth.

Patients diagnosed with increased tooth mobility may need only an occlusal

equilibration, perhaps conventional splint therapy.

Individuals diagnosed with increasing tooth mobility must first receive periodontal

therapy. Treatment should include an occlusal analysis and equilibration, if needed,

followed by a reevaluation for extraction or splinting of the affected teeth.

OBJECTIVES OF SPLINTING

Rest is created for the supporting tissues giving them a favorable climate for repair of trauma.

Reduction of mobility immediately and hopefully permanently. In particular jiggling

movements are reduced or eliminated.

Redirection of forces - redirected in a more axial direction over all the teeth included in the

splint.

Redistribution of forces - ensures that forces do not exceed the adaptive capacity.

Forces/received by one tooth are distributed to a number of teeth.

Restoration of functional stability - functional occlusion stabilizes mobile abutment teeth.

To preserve arch integrity - restores proximal contacts, reducing food impaction

& consequent break down.

To stabilize mobile teeth during surgical, especially during regenerative

periodontal therapy.

To prevent migration and over eruption.

Psychologic well being - gives the patient comfort from mobile teeth a sense of

well being.

Masticatory function is improved.

Discomfort and pain are eliminated.

INDICATIONS

Stabilize teeth when tooth mobility interferes with normal masticatory function and comfort of the patient

Stabilize teeth in secondary TFO

To prevent tipping of the teeth Prevent extrusion of unopposed teeth

Stabilization of mobile teeth during surgical especially

regenerative therapy.

Stabilize teeth following orthodontic movement

CONTRAINDICATIONS FOR SPLINTING

Splinting teeth is not recommended if occlusal stability and optimal

periodontal conditions cannot be obtained.

Insufficient number of firm / sufficiently firm teeth to stabilize mobile teeth.

PRINCIPLES OF SPLINTING:

The main objective of splinting is to decrease movement three-dimensionally.

This objective often can be met with the proper placement of a cross-arch

splint.

Conversely, unilateral splints that do not cross the midline tend to permit the

affected teeth to rotate in a faciolingual direction about a mesio-distal linear

axis.

AN IDEAL SPLINTsimple and hygienic

economic

stable and efficient

Non irritating

not interfere

with treatment

esthetically

acceptable

not provoke

iatrogenic disease

MODE OF ACTION

Loose teeth splinted to adjacent firm teeth may become stabilized.

When many teeth are loose, adjacent sextants should be included in the splint.

Cross-arch splinting reduces mobility to the least common value.

Teeth are thus immobilized occlusal forces are better distributed

traumatism minimized repair is enhanced teeth may become firm

again.

Even when teeth do not tighten, the splint serves as an orthopedic brace that

permits useful function of mobile teeth.

Teeth with reduced support often are hypermobile and may gradually

increase if the teeth are not splinted.

Classification OF SPLINTS

Splints, like bridges may be fixed, removable, or a combination of both.

They may be temporary, provisional, or permanent, according to the type of material

and duration of use.

They may be internal or external, depending on whether tooth preparation is required

or not.

Permanent splinting of teeth that have been treated periodontally is also referred to as

periodontal prosthesis.

A) According to the period of Stabilization(Grant and Listgarten,1988)a) Temporary Stabilization: worn for less than 6 months. Removable Hawley appliance with arch wire Fixed Intracoronal AmalgamAmalgam & Wire Amalgam , Wire & Resin Composite Resin & Wire

Extracoronal

Stainless steel wire with resins

Wire & Resin with acid etchin

Orthodontic soldered bands, Brackets & Wire

b) Provisional splinting: to be used for months up to several years.

e.g. Acrylic splints, Metal band etc.

c) Permanent Splints: used indefinitely

Removable/Fixed

Extra/Intracoronal

Full/Partial veneer crowns soldered together.

Inlay/Onlay soldered together.

B) According to the type of material:

Bonded composite resin splint

Braided wire splint

A – Splints.

C) According to the location on the tooth:

Intracoronal

Composite resin with wire

Inlays

Onlays

Extracoronal

Tooth Bonded plastic and Welded bands

Goldman, Cohen and Chacker Classification:

Temporary splints

A. Extra coronal type

Wire ligation

Orthodontic bands

Removable acrylic appliances

Removable cast appliances

Ultraviolet-light-polymerizing bonding materials

B. Intracoronal type

Wire and acrylic

Wire and amalgam

Wire, amalgam, and acrylic

Cast chrome-cobalt alloy bars with acrylic, or both.

Provisional splints

All acrylic

Adapted metal band and acrylic

Ross, Weisgold and Wright Classification:

A. Temporary stabilization

Removable extra coronal splints

Fixed extra coronal splints

Intracoronal splints

Etched metal resin-bonded splints

B. Provisional stabilization

Acrylic splints

Metal-band-and-acrylic splints

C. Long-term stabilization

Removable splints

Fixed splints

Combination removable and fixed splints

Before construction of any splint for periodontally involved dentitions, certain basic considerations

should be applied whenever possible:

For most patients, splinting should be considered only after the preliminary phase of

periodontal therapy has been completed.

Exceptions …

Coronal portions of the teeth…. the extracoronal method of splinting ..

If the teeth obviously require extensive restorative therapy + periodontal

therapy a form of intracoronal splinting…justified and preferable.

The extent of splinting….the number of teeth involved…. degree of their

mobility.

In all cases, a sufficient number of nonmobile teeth should be included in the

splint.

Support of posterior teeth …. when anterior segments are mobile.

If, in a case of occlusal trauma associated with severe bone loss…all the teeth

demonstrate hypermobility…cross arch splinting is beneficial.

TEMPORARY STABILIZATION Temporary stabilization is essentially a diagnostic procedure that, ideally, should be

reversible in nature.

…a mechanical stabilization … decrease of hypermobility of the involved teeth with

time…expected..

Indications for Temporary Stabilization

Temporary splints are used… until hypermobility is satisfactorily reduced or eliminated

and the teeth can function without the help of the splint….until the dentition clearly

requires long term stabilization.

The term temporary is applied

To a splint that is used until stabilization is no longer necessary, for

example, in cases of mobility caused by orthodontic repositioning,

accidental or surgical trauma, or occlusal traumatism, all of a reversible

nature.

As a phase in the therapy being undertaken to determine whether

mobility can be resolved by conservative methods or whether mobility

is caused by loss of support sufficient to create permanent mobility.

When advanced periodontal disease dictates permanent fixation by extensive

restorative methods, but ….

(a) For economic reasons or

(b) Because prognosis for all remaining teeth is extremely doubtful or

(c) Because poor health seriously affects the longevity of the dentition

(d) Because the patient cannot emotionally accept the lengthy procedures of

permanent fixation.

For temporary stabilization, the method … simplest, least expensive, and least

time consuming to construct, esthetically acceptable to the patient, and should

meet the needs of the individual.

The functions of a temporary splint may be listed as follows:

To protect mobile teeth from further injury by stabilizing them in a favorable

occlusal relationship.

To distribute occlusal forces so that teeth that have lost periodontal support

are not further traumatized.

To aid in determining whether teeth will respond to therapy.

extracoronal

Almost all the extracoronal forms of stabilization have certain inherent

disadvantages.

It is often difficult to perform various surgical procedures in these areas

because of the nature of the appliance.

Cosmetically…not very satisfying..

Wire ligation:

Most commonly used type of stabilization.

Easy to construct.

Basic limitations is that it can be utilized only where coronal form permits.

Because of this shortcoming it has its greatest use in stabilizing the

mandibular incisors.

After an interproximal tie is made, connecting the buccal and lingual

segments of the mesh, tooth-colored, self-curing acrylic maybe placed over

the wire to obtain a more pleasing aesthetic result.

Orthodontic bands:

Stabilizes both anterior and posterior teeth and so have the advantage over wire ligation in that they

are not limiting.

It is important to give proper attention to the contours of the bands and to check their relationship to

the adjacent gingival tissue.

Often the contacts between the teeth must be opened ….. a band or bands can be inserted.

Again, acrylic may be placed over the bands for cosmetic purposes.

When the multiple bands are welded together, it is necessary to have a common path of insertion so

that the fit of the multiple bands is the same as the fit of each individual band.

Removable acrylic appliances:

If we utilize any form of acrylic appliance, the dimensional instability of the material may cause

distortions to occur.

It is imperative to check these appliances frequently and to make any necessary adjustments.

Acrylic bite guards ( Night Guards):

Night guards can be constructed in many ways, and they have a wide variety of

uses like treatment of bruxism and clenching.

The most common type of appliance is one that covers the occlusal surfaces of

the teeth. For additional support the palate is often covered.

Advantage : the teeth are freed of occlusal contact in all positions and excursions

of the mandible.

An important consideration with all these appliances is that they must not

obliterate the interocclusal distance (free-way space).

Removable cast appliances:

The removable cast appliance is usually a rigid casting either of gold or of chrome cobalt,

made to fit around the teeth.

One end usually the anterior section, is not joined but is left open so that the casting can be

sprung over the undercuts and then ligated.

The posterior end is continuous from the buccal to the lingual surface.

Another modification ….. interlocking attachment on the distal end so that the appliance can

be locked after being sprung over the teeth.

Ultraviolet Light Polymerizing bonding materials:

Restorative materials that are polymerized by ultraviolet light are very useful in

providing stabilization of excessively mobile teeth.

These materials do not polymerize until they are exposed to ultraviolet light, they

provide prolonged working times for placement. shaping, and contouring, over extensive

areas of enamel.

Basically the technique is a simple one and provides adequate stabilization if care is

taken during the actual operative procedures.

The composite resin splint can be strengthened by adding wire, monofilament line to

reinforce the material.

Extracoronal resin-bonded retainers, which can be fabricated in the dental laboratory,

serve to strengthen the overall bonded situation.

The splints are usually cast from metals, usually non noble alloys that can be

electrolytically or chemically etched.

This type of splint has greater inherent strength than a composite-resin splint created intraorally.

Extra features such as grooves, pins and parallel preparations increase the retentive capacity of

these splints.

No long-term clinical data are available for these materials; however, they seem promising

at this time.

INTERNAL SPLINTS

Internal temporary splints should be used only when permanent splinting is to follow.

They may also be used on a provisional basis when tooth prognosis is guarded. Even when splinting cannot save teeth, it can provide a gradual and less

distressing transition to full dentures. Once an internal temporary device has been used, the patient may be committed

to periodontal prosthesis.

Acrylic splints

A channel approximately 3 mm wide and 2 mm deep in several teeth.

Undercut for retention

Pulpal surfaces should be coated with a protectant

Platinized knurled wire in channel

Place self cure acrylic to fix wire in channel and polish

Advantages

Minimal tooth preparation is requiredEsthetic

Disadvantages

Tend to harbor plaque which can lead to caries, calculus deposition and inflammationThe maintenance needs are increased.If pulp protection is not given, pulp involvement may occur.

Composite Splint

Amalgam Splint

Acrylic Full Crowns

• Fixed temporary bridges may be made of acrylic crowns and pontics and may also serve as temporary splints.

• They are used when permanent fixed splints will ultimately replace them.

DISADVANTAGES The material tend to wear and break. Tend to harbor plaque which can lead to caries, calculus deposition and

inflammation The maintenance needs are increased

PROVISIONAL SPLINTING

Provisional restorations serve to stabilize a permanently mobile dentition from the time of initial tooth preparation until the time the dentition is periodontally stable enough for permanent restorations

It provides stability, occlusal function, and a good esthetic

result

In addition, it allows the dentist to determine the optimum esthetic

and functional design to be

incorporated into the future

permanent splint.

The provisional splint can be

placed any time after the initial

periodontal therapy is complete

If the splint is seated using temporary

cement, it can be removed during

periodontal treatment, thus

facilitating access to the root surfaces

PERMANENT SPLINTING: PERIODONTAL PROSTHESIS

Permanent splinting is indicated whenever periodontal treatment does not reduce mobility to the point at which the teeth can function without added support.

Such devices serve to stabilize loose teeth, to redistribute occlusal forces, to reduce traumatism, and to aid in the repair of the periodontal tissues

Permanent splints are fabricated after periodontal treatment has been completed, when their use will extend the functional lifetime of the teeth.

Indications for splinting the patient with advanced periodontal disease using fixed cast restorations (Lindhe et al in 1983)

Progressive mobility of teeth as a result of gradually increasing width of the periodontal ligament in teeth with loss of alveolar bone height.

Indicated when mobility disturbs chewing ability or comfort.

Contraindications

Splinting with fixed cast restorations is not indicated

if occlusal stability cannot be obtained with the provisional

acrylic bridge.

Splinting is not indicated for the patient who is

comfortable during normal mastication yet has increased mobility of a tooth or teeth with loss of alveolar bone

and a normal width of periodontal ligament without

increasing mobility

Objectives For Splinting With Fixed prosthesis

the patient is able to function comfortably

tooth mobility is normal or at least no

longer increasing

the splinted fixed prosthesis also serves to replace any missing

teeth

Removable Splints

Incorporate continuous clasps that brace loose teeth.

They strongly resemble partial dentures, and their features may be included in partial dentures.

They support the teeth from the lingual surface and may incorporate additional support from the labial surface.

Swing Lock Devices

Over Denture

Literature review on splinting

Rengglie et al 1984 studied the use of bridges placed 3 to 4 months  following the surgical therapy.  This bridge is then removed daily for oral hygiene.  The mobility of the abutment teeth did not have an increase in mobility. 

The interesting thing about the study was that the mobility of the non-splinted teeth was also reduced.  Therefore, the author concluded that harmonious occlusion is the reason why all the teeth lost their mobility, not the splinting.

Kegel et al 1979 studied mobility of the teeth after scaling and root planning, occlusal adjustment, and oral hygiene using 7 patients, split mouth design.  They found there were no change in tooth mobility between splinted and non-splinted groups of the teeth.

 There were also no difference in bleeding on probing, gingival bleeding, attachment level, or radiographic bone scores.  Splinted teeth did not have any clinical advantage over the non-splinted teeth.

Glickman et al. (1961) evaluated the effects of splinting teeth in hyperocclusion using five Rhesus monkeys. The forces which applied to 1 tooth in a splint were transmitted to all teeth within the splint. The direction of the initial force was maintained and comparable areas of the splinted periodontium were affected.

The bifurcation areas were most susceptible to excessive force. Forces applied to non-splinted teeth were not transmitted to adjacent teeth.

Galler et al. 1979 also used split mouth design during and following the osseous surgery.  During the follow-up period of 24 weeks, it was observed that splinting had no effect on mobility at any time during the examination.

 There were no differences between the two groups in terms of mobility and the amount of the bone removed, regardless of whether the teeth were splinted or not-splinted.  The post-operative mobility was only dependent on the pre-operative mobility.

Nyman et al. (1975) studied 20 patients who had originally exhibited severe periodontal breakdown and extensive tooth loss. Extensive fixed bridgework was placed following periodontal therapy and the patients monitored for 2 to 6 years.

No further bone loss was observed between the insertion of the fixed bridgework and the final examination. The authors reported no increase in PDL width of the abutments or changes in mobility.

Schulz A in 2000 conducted a study to evaluate the effect of splinting teeth on the results of periodontal reconstructive surgery using a specific carbonate bone replacement graft (BRG) material. Forty-five patients were randomly treated with a periodontal surgery approach. In the presplint group, teeth were splinted to at least two rigid teeth before surgery, in the postsplint group, teeth were splinted at suture removal, and in the nonsplint group, the treated teeth were not splinted at all.  

A decrease in PPD and tooth mobility and a gain of CAL were seen following the use of BRG in presplint teeth. In the same group, PPD and tooth mobility were significantly reduced compared to nonsplint teeth. The less favourable improvement in periodontal function of postsplint or nonsplint teeth seemed to be due to the loss of BRG material caused by tooth mobility. These results indicate that an undisturbed wound healing process using BRG together with tooth stability is beneficial to overall clinical success.

DRAWBACKS OF SPLINTING

Gingival irritation

Difficult oral hygiene access

Crown becomes loose or fractured

interference of the splint to

normal interproximal

wear and mesial drift

Interference with phonetics

conclusion

Splinting mobile teeth acts as an adjunct to periodontal treatment and maintenance and hence is recommended.

However , selecting the right splint for the right case is important. Splint should be designed such that … Thus splinting can be considered as an essential part of periodontal

treatment to increase the longevity of periodontally compromised teeth with mobility.

REFERENCES

Carranza’s clinical periodontology 10th edition Lindhe 4th edition Grant 6th edition Kathariya R, Devanoorkar A, Golani R. To splint or not to splint: The

current status of periodontal splinting. Journal of the international academy of periodontology 2016;18(2):45-56.

Sturer,nyman, Niklaups, Lang. Tooth mobility and the biological - rationale for splinting teeth. Periodontology 2000.1994;4:15-22.